January 16, 2016
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Shared decision making critical with expanding treatment options

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As we begin yet another new year, I always like to reflect on the year gone by and to consider what the upcoming year holds.

The year 2016 marks a number of professional milestones for me, perhaps none more noteworthy than the fact that it is my 25th year of comanaging refractive surgery patients. Prior to 1991, my exposure to refractive surgery was fairly limited, mainly providing therapeutic contact lenses for radial keratotomy mishaps. It was an experience that taught me just how powerful – and yet vulnerable – the cornea is as a refractive medium. It was also the reason we proceeded cautiously in recommending excimer laser-based refractive surgery to our patients and why we were so attentive in monitoring their postoperative course.

Back then, PRK was the procedure and we were largely in unchartered waters, sorting through laser fluences, ablation zone diameters and considerations in managing wound healing as well as postoperative pain management. Needless to say, there was a lot of give and take as we listened carefully to patients, tweaked treatment protocols and did a lot of “hand holding.” In every sense it was our first foray in doctor-patient shared decision making (SDM).

Michael D. DePaolis

In early 1994 I had the pleasure of meeting Dr. Jeffery Machat, a LASIK pioneer and cofounder of TLC. Given the fact that there were no LASIK surgeons in our area at the time, and given Toronto’s proximity to Rochester, we began referring interested patients to TLC. As LASIK was very much an emerging technology, we, once again, proceeded cautiously.

I remember detailed preoperative evaluations, lengthy patient consultations and an almost obsessive degree of communication between our office and TLC. We wanted nothing more than to provide our patients – many of whom were unable to wear contact lenses – with the most contemporary surgical alternatives while, above all, doing no harm. Much like in the early days of PRK our decisions were inevitably based on a consensus among patient, optometrist and surgeon. To this day, I believe SDM played a significant role in the success of LASIK in those early days.

Over the past 2 decades we have all witnessed the emergence of full-thickness corneal imaging, higher-order aberration (HOA) recognition, custom LASIK treatments and “bladeless” femtosecond laser procedures. In the process, LASIK has become incredibly safe and effective. Equally importantly, it has become mainstream. While today’s LASIK is a viable option for even those with higher prescriptions, large pupils, thinner corneas and certain HOAs, it is still not for everyone – a consideration that makes SDM more important than ever.

As we begin 2016 I sense yet another evolution in refractive surgery. Many of our LASIK patients have reached the age of presbyopia, with some even manifesting cataracts. It is comforting to know we have options such as intracorneal inlays (Kamra) and specialty IOLs to address their ongoing refractive and therapeutic needs. While these technologies are arguably even more impressive than the excimer laser of 20 years ago, their success will still largely hinge upon patients and eye care providers embracing SDM.

In this issue of Primary Care Optometry News, we provide a closer look at SDM in our features, “Shared decision making can lead to better, individualized care” and “Close comanagement relationship results in optimal patient outcomes” . I am sure you will agree that as treatment options become more numerous, complex SDM becomes even more critical in their implementation.

From all of us at Primary Care Optometry News, thank you for your continued readership and best wishes for a happy, healthy and prosperous 2016.

Disclosure: DePaolis reports no relevant financial disclosures.